Focus on Emergency and Disaster Nursing

Focus on Emergency and Disaster Nursing

•(Relates to Chapter 71,72 “Nursing Management: Emergency and Disaster Nursing” in the textbook)

•Apply the sequential steps in triage,

•Describe the pathophysiology, assessment, and collaborative care of select environmental emergencies

•Describe the pathophysiology, assessment, and collaborative care of select toxicological emergencies.

•Identify the agents most likely to be used in a terrorist attack.

•Differentiate the responsibilities of health care providers, the community, and select federal agencies in emergency and mass casualty incident preparedness.

Scope and Practice of Emergency Nursing

•Emergent, urgent, and critical care needs

•An emergency is whatever the patient or family considers it to be

•The emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations

Emergency Nursing

•Patients with life-threatening or potentially life-threatening problems enter the hospital through the emergency department (ED)

Triage

–Process of rapidly determining patient acuity

–Represents a critical assessment skill

•Triage process

–Patients who have a threat to life, vision, or limb are treated before other patients

•Triage system: Categorizes patients so most critical are treated first

•Emergency Severity Index:
Five-level triage system that incorporates illness severity and resource utilization

•Primary survey focuses on airway, breathing, circulation, and disability (ABCD)

–Identifies life-threatening conditions

–If life-threatening conditions related to ABCD are identified during primary survey, interventions are started immediately and before proceeding to the next step of the survey

Primary Survey

•Airway with cervical spine stabilization and/or immobilization (shortness of breath, inability to vocalize, etc.)

•Breathing (non-rebreather, bag-valve mask, etc.)

•Circulation (check central(femoral, carotid, apical) and peripheral pulse; assess skin-moisture, color, cap refill; start fluids)

•Disability (AVPU- Alert; Voice response; Pain response; Unresponsive –Glasgow Coma Scale - Chk pupils)

Secondary Survey

Definition: Brief, systematic process to identify all injuries

•Exposure/Environmental control (look at entire body, temp control)

•Full set of vital signs/Five interventions/Facilitate Family presence (Vitals, Monitor, Foley, NG Tube, Blood Draw)

•Give comfort measures (Pharmacology, splinting, icing…etc.)

•History and Head-to-toe assessment (Hx of injury, illness…talk to family, ems….inspect head-to-toe)

•Inspect the posterior surfaces (log roll)

–Evaluate need for tetanus prophylaxis

–Provide ongoing monitoring

–Prepare to----

Death in the Emergency Department

•Must recognize importance of hospital rituals in preparing the bereaved to grieve (e.g., collecting belongings, viewing the body)

•Determine if patient could be candidate for non–heart beating donation

•Medical examiner

Gerontologic Considerations: Emergency Care

•Elderly are at high risk for injury—

–Decreased visual acuity and peripheral vision

–Hearing loss

•Especially to high frequency sounds

–Pre-existing disease and medication use

–Dementia and cognitive impairment

Heat Exhaustion

•Prolonged exposure to heat over hours or days

•Leads to heat exhaustion

•Clinical syndrome (fatigue, nausea, vomiting, diarrhea, feelings of impending doom, profuse diaphorisis, mild to severe temp elevation – 99.6-104

•Treatment……..(place in cool environment, place cool moist sheet over them, oral fluids, start IV NS, give electrolytes. May not be able to handle oral treatment)

Heat Stroke

•Failure of the hypothalamic thermoregulatory processes

•Vasodilation, increased sweating and respiratory rate deplete fluids and electrolytes, specifically sodium

•Sweat glands stop functioning and core temperature increases (>104º F [40º C])

•Heat exhausted person that doesn’t get treated and continues on what they are doing

•TREATMENT: Remove clothing, cover with wet sheets, place in front of large fan, possible emerse in icewater bath, and administer cool fluids, lavage cool fluids.

•Shivering: Increases core temperature, complicates cooling efforts, treated with IV chlorpromazine

•Aggressive temperature reduction until core temperature reaches 102º F
(38.9º C)

•Monitor for signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular coagulation

24 Hours after Frostbite Injury (PIC ON POWERPOINT)

*Causes peripheral vasoconstriction

*The depth of the frostbite is a result of the ambient temp, the length of exposure and the type and condition of the clothing surrounding the injury, and whether or not the pt was surrounded by metal surfaces, as well as proper vascular status

*Control with controlled but rapid rewarming (circulating bath 30-40 min intervals-very painful-give pain med)

Deep frostbite involves bone, muscle tendons – be very careful with friction to injury

Gangrenous Necrosis 6 Weeks after Frostbite Injury (PIC ON PP)

Hypothermia

•Mild hypothermia(93.2º to 96.8º F
[34º to 36º C])

–Core temperature <95º F (<35º C)

•Moderate hypothermia(86º to 93.2º F [30º to 34º C])

–Core temperature <86º F (30º C) is potentially life-threatening

•

•Profound hypothermia(<86º F [30º C])

–Coma results when core temperature
is <82.4º F (28º C)

•Death usually occurs when core temperature is <78º F (25.6º C)

Treatment of hypothermia

• ABCD’s, correct any acidosis

•Mild hypothermia: Passive or active external rewarming, monitor HR

•Moderate to profound hypothermia: Active core rewarming, must be monitored continuously

–Air-filled blankets, warm IV fluids, heated or humidified air, heat lamps

Risks of rewarming

•Rewarming should be discontinued once the core temperature reaches 95º F (35º C)

•Warm patient to at least 90º F (32.2º C) before pronouncing dead

•AFTERDROP – further drop in core temp for unknown reasons

•HTN

•Dysrythmias - must put pt on Cardiac monitor!!

Submersion Injury

•Results when person becomes hypoxic due to submersion in water

•Drowning: Death from suffocation after submersion in water

–Immersion syndromeoccurs with immersion in cold water, which leads to stimulation of the vagus nerve and potentially fatal dysrhythmias

–Near-drowning: Survival from potential drowning

•Aggressively resuscitate

Pulmonary Effects of Water Aspiration

Treatment of submersion injuries

•Initial evaluation: ABCD

•Mechanical ventilation

•Correct acid/base, fluid imbalance

•Rewarm if needed

•PEEP – due to surfactant destruction

Submersion Injury Result

•Deterioration in neurologic status: Cerebral edema, worsening hypoxia, profound acidosis

•Observe for minimum of 4 to 6 hours

•Delayed pulmonary edema* (secondary drowning): Delayed death from drowning due to pulmonary complications

Animal Bites

•Children at greatest risk

•Most common

–Dog and Cats

•Complications

–Infection (higher risk with cat bites)

–Mechanical destruction of the skin

–Deep puncture wounds (tendons)

Human Bites

•Result in puncture wounds or lacerations

•VERY high risk of infection

•Common sites – Hands et ears

Animal and Human Bites

•Initial treatment

–Puncture wounds left open

–Lacerations loosely sutured

–Wounds over joints splinted

–Rabies prophylaxis essential in management of animal bites (series of 5 injections, day 0, 3,7,14 and 28)

Poisonings

•Chemicals that harm the body accidentally, occupationally, recreationally, or intentionally

•Severity depends on type, concentration, and route of exposure

Management:

–Decrease absorption

–Dermal cleansing/eye irrigation

–Water mixes with mustard gas and releases chlorine gas

•Decontamination takes priority over all interventions except basic life support measures

•Enhance elimination

–Don’t want to induce vomiting…don’t want to cause more damage having it come back up.

•Hemodialysis/hemoperfusion

•Implement toxin-specific interventions per poison control center

Management Patients WithCarbon Monoxide Poisoning

•Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen

•Manifestations: CNS symptoms predominate

–Skin color is not a reliable sign and pulse oximetry is not valid (because CO2 binds with O2, nothing is getting released)

•Treatment

–Get to fresh air immediately

–Perform CPR as necessary

–Administer oxygen: 100% or oxygen under hyperbaric pressure

Violence

•Acting out of emotions (e.g., fear or anger) to cause harm to someone or something

•Antisocial behavior

•Violence can occur in a variety of settings (e.g., home, community, workplace)

•EDs high-risk areas for workplace violence

Domestic Violence

•Pattern of coercive behavior in a relationship

•Found in all professions, cultures, socioeconomic groups, ages, and genders

•Screening for domestic violence is required in ED

•Appropriate interventions

Terrorism - Bioterrorism

•Involves overt actions for the expressed purpose of causing harm

•Anthrax, plague, and tularemia

•Smallpox

•Botulism

•Hemorrhagic fever

Chemical Agents of Terrorism

•Categorized by target organ or effect

–Sarin

–Antidotes for nerve agents - atropine

–Phosgene (colorless gas – normal used in chemical manufacturing – can cause pulmonary edema –death)

–Mustard gas (yellow/brown color, garlic odor – irritates eyes- burns/blisters skin-treat with lots of water, blot/dry skin)

Radiologic/Nuclear Agents of Terrorism

•Radiologic dispersal devices (RRDs) (“dirty bombs”)

–Main danger from RRDs:Explosion itself

•Ionizing radiation (e.g., nuclear bomb, damage to a nuclear reactor)

•Exposure may or may not include skin contamination with radioactive material

•Follows a predictable pattern

Explosive Devices as Agents of Terrorism

•Result in one or more of following types of injuries: Blast, crush, or penetrating

•Damage to the lungs, middle ear, gastrointestinal tract

Emergency and Mass Casualty Incident Preparedness

•Emergency Preparedness

•Mass casualty incident (MCI)

•MCIs usually involve large numbers of casualties (>100

•MCIs always require assistance from people/resources outside community

–American Red Cross (Have to manage your own facility for 72 hrs before FEMA will step in and help.)

•Triage of casualties differs from usual ED triage and is conducted in<15 seconds

–System of colored tags designates both seriousness of injury and likelihood of survival

•Green (minor injury)

•yellow (non-life threatening)

• Red (life threatening)

•Black (death likely)

•Casualties need to be treated and stabilized

•Many casualties will arrive at hospitals on their own (i.e., “walking wounded”)

•Total number of casualties a hospital can expect is estimated by doubling number of casualties that arrive in first hour

•Communities have initiated programs to develop community emergency response teams (CERTs)

•Life-saving skills with emphasis on decision making and rescuer safety

•All health care providers have a role in emergency and MCI preparedness

•Response to MCIs often requires the aid of a federal agency such as the National Disaster Medical System (NDMS)

•NDMS: Organizes and trains volunteer disaster medical assistance teams (DMATs)

–DMATs: Categorized according to ability to respond to an MCI

–DMAT—disaster medical assistant teams….can be deployed in 8 hrs and can be ok for about 72hrs. Can treat about 200 people per day.

–Level 2- self sufficient and used to replace the level 1 team *back-up*

•Many hospitals and DMATs have a Critical Incident Stress Management unit

–Arranges group discussions to allow participants to verbalize and validate their feelings and emotions about the experience

All Hazards Preparedness

•Disaster Task Force

•Emergency Management Team

–Incident Command

–Disaster Plans

–Surge Capacity

–Lockdown Plan

–Staffing Plan

•General

•Human Resources

•Safety and Security

•Communication

•Logistics

•Clinical Operations

•Financial

•Media and Messages

•First Rule

•Keeping Staff Safe

•Summary

•When we accept tough jobs as a challenge and wade into them with joy and enthusiasm, miracles can happen.

• Harry S. Truman